This application is for salary support for Dr. Curtis under the K24 mechanism. This support will relieve him from clinical and administrative duties and allow him to redirect his research program to patient-oriented studies and the mentoring of new clinical investigators. This K24 award will have the support of the Division of Pulmonary and Critical Care Medicine at the University of Washington and the fellowship-training program of this Division. The projects are designed to measure and improve the quality of communication with patients and families about end-of-life care for patients with COPD and critical illness with respiratory failure. The specific aims are: Project 1: Measuring and improving the quality of communication about end-of-life care in severe COPD. 1) Develop and validate a measure of the quality of patient-physician communication about end-of-life care for persons with severe COPD. 2) Determine whether increased quality of communication is associated with increased quality of end-of-life care. 3) Assess the role of culture and ethnicity in communication about end-of-life care. 4) Develop and evaluate culturally-sensitive interventions to improve the quality of patient-physician communication about end-of-life care for patients with severe COPD. Project 2: Measuring and improving the quality of communication in the ICU family conference. 1)Describe the content and process of clinician-family communication about end-of-life care occurring as part of ICU family conferences using qualitative analysis based on grounded theory. 2) Evaluate the quality of clinician-family communication about end-of-life care occurring as part of ICU family conferences using a combination of qualitative and survey methods. 3) Examine the reliability and validity of a questionnaire assessing the quality of clinician-family communication about end-of-life care occurring as part of ICU family conferences. 4) Assess key components of cultural competence in cross-cultural ICU family conferences. 5) Develop and evaluate culturally-sensitive interventions to improve the quality of clinician-family communication.